Intake Form Retreats | Breakthrough WellBEing

1 Day Yoga Retreat Denver, NC October 19, 2025

First Name*

Last name*

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Age*

Occupation*

Please Explain Any Physical Pain:

What outcome do you want from this retreat (e.g., feel relaxed, peace, insight, etc.)?*

Any Medical or Allergy or Other Information We Should Be Aware Of?

Please provide an emergency contact / phone:*

I understand this retreat is designed to promote health and well-being. Its aim is to help the body relax through movement and gentle reflection. All activities are optional and NOT required. This retreat is NOT meant to be therapy or to be a substitute for therapy. This retreat is NOT staffed by licensed therapists. It is your responsibility to address any trauma or PTSD with an appropriate professional. If you find yourself being emotionally or mentally triggered by a meditative prompt or anything external or internal to yourself, it is YOUR responsibility to take care of yourself – finding mental/emotional safety – removing yourself from the trigger and/or asking a leader for assistance. It is our aim to create a safe, welcoming space, but we don’t know how you might hear a meditative prompt and where your thoughts may lead. You have to take responsibility to manage triggers, if encountered. If you have a situation in your life that causes stress beyond what would be considered everyday stressors, it is your responsibility to decide if you want to reflect on that stressor or not. Any activity at the retreat is designed to help you move toward improved health and well-being (by relaxing the body), but not to process troubling issues (those issues should be addressed with a licensed therapist or a fully-certified yoga therapist). ***I AM Yoga may include the use of appropriate touch to improve range of motion, alignment, and body awareness. Please choose one of the following below:*

I give Consent for my yoga consultant to use hands-on contact to assist my yoga session. I agree to communicate with my yoga consultant about any particular techniques involving touch that I would prefer to drop or discontinue. I understand that I can inform the yoga consultant of my change in preference in this or future sessions, and that this change in preference will be documented.

I prefer a touch-free yoga session. If the yoga consultant absolutely feels they must engage touch for safety in the pose, I understand they will ask permission to assist first. I understand that I can inform the yoga consultant of any change in preference in this or future sessions, and that this change in preference will be documented.

Informed Consent: I understand that yoga includes physical movements as well as an opportunity for relaxation, stress reduction, and a relief of muscular tension. I understand that I will receive information and instruction; including verbal and physical adjustments about yoga and health. I further understand that any information provided by the instructor is the opinion of the instructor and is not, in any way, intended to be a diagnosis or treatment for any medical issue, illness, or injury. As is the case with any physical activity, the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. I understand that because yoga practice and/or specific poses are not recommended for individuals with certain health conditions (e.g., cardiac illness, later stages of pregnancy, post-surgery), it is my responsibility to consult with a physician and, when necessary, obtain a doctor’s release prior to my participation in the yoga class. I represent and warrant that I am physically fit and I have no medical condition that would prevent my full participation in the yoga class. I am aware the teacher may offer physical adjustments and I have the right to refuse adjustment at any time even if I have agreed in the past. I agree to inform the instructor if I feel any pain or discomfort during the session and that I may choose to stop participating or leave at any time. I understand that my teacher is not a medical professional and that a medical practitioner should address any medical questions. Liability Waiver: I agree to take full responsibility for any risks, loss, claim, injury, damage, or liability, known or unknown, which I might incur as a result of participating in the program. Yoga is not a substitute for medical attention, examination, diagnosis or treatment. Yoga is not recommended and is not safe under certain medical conditions. I affirm that I am alone and am responsible to decide whether to practice yoga. I knowingly, voluntarily, and expressly agree to accept full responsibility and assume the risk for my participation in any and all classes, activities, apparatus, appliance, facility privilege or service, of any nature, which is owned, made available, or operated by Breakthrough WellBEing. While engaging in any class or activity operated, organized, arranged, or sponsored by Breakthrough WellBEing, I shall do so at my own risk, and hold Breakthrough Wellbeing, its employees, representatives, and agents, forever harmless from any and all loss claim, injury, damage, or liability sustained or incurred by me. I specifically agree to indemnify and hold harmless Breakthrough WellBEing as to any loss, cost, claim, injury, damage, or liability, sustained or incurred by participating in the classes, or through my use of facilities or equipment of Breakthrough WellBEing which is caused by an act or omission, whether negligent, intentional or otherwise, of an employee, representative, or agent of Breakthrough WellBEing. I, my heirs, or legal representative forever release waive, discharge, and covenant not to sue Breakthrough WellBEing for any injury or death cause by my participation in the yoga class. My signature below constitutes my full acceptance of the waiver. I have read the release and waiver of liability and fully understand its consent. I voluntarily agree to the terms and conditions stated above.*

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